No long-term changes in psoriasis severity and quality of life following climate therapy

Long-term evaluation of climatotherapy for psoriasis

Climatotherapy (CT) is a treatment with immediate high clearance rate for chronic psoriasis, but evidence of long-term effects is scarce. Assessment of the impact of a single CT treatment on disease activity and quality of life was carried out at 4- to 6-month follow-ups. A prospective study of patients with psoriasis undergoing 4 weeks of CT in Israel describes long-term outcomes of CT. Psoriasis Area Severity Index (PASI) and Dermatology Life Quality Index (DLQI) scores were assessed before CT and at an average of 5 months after return. Assessment of the eligibility for CT takes place twice a year. A total of 49 patients (28/21 M/F) participated. Pretreatment PASI was 2.6 to 18.7 (mean 8.1 ± 3.8) vs control PASI 0 to 16.9 (mean 5 ± 2.8), (P < .0001). Mean ΔPASI was 3.2 (39.5% reduction). PASI 75 was achieved by 11/49 patients; 10/49 had increased PASI. The mean DLQI score was 16.1 (range 2-30); 10.6 at follow-up (range 0-28), and 33 patients achieved DLQI minimal clinically important difference (P < .0001). Age, sex, number of previous CT, and duration of observation period did not affect endpoints. CT and unmonitored self-treatment induces PASI 75 in one-fifth patients at follow-up 4 to 6 months later. Six of 10 patients report a clinically important improvement of patients' quality of life as measured by DLQI.

Psoriasis treatment: Unconventional and non-standard modalities in the era of biologics

Psoriasis is a potentially debilitating inflammatory dermatosis affecting 0.2%-4.8% of the population worldwide causing a significant occupational, personal or psychosocial morbidity to these patients for life. The basic aim of psoriasis therapy is to control the disease to maximum possible extent and improve the patient’s quality of life. Management of triggers for flare-ups, lifestyle modifications, and dietary supplements are often recommended. Intermittent or rotational therapy with frequent alterations in treatment options is usually needed to reduce toxicity of anti-psoriatic drugs in the absence of safer alternatives. Currently, several biological agents categorized as either T-cell targeted (e.g., Alefacept, Efalizumab) or cytokine modulating (e.g., Adalimumab, Infliximab, Etanercept) are available for treating severe psoriasis. However, their high cost is often precluding for most patients. The usefulness of systemic (methotrexate, cyclosporine, acitretin or several other therapeutic agents) or topical (tar, anthralin, corticosteroids or calcipotriol ointments, phototherapy with or without psoralens) therapies has been well established for the management of psoriasis. The literature is also replete with benefits of less used non-standard and unconventional treatment modalities (hydroxycarbamide, azathioprine, leflunomide, mycophenolate mofetil, isotretinoin, fumarates, topical calcineurin inhibitors, peroxisome proliferator-activated receptors agonists, statins, sulfasalazine, pentoxifylline, colchicine, grenz ray therapy, excimer laser, climatotherapy and balneophototherapy, peritoneal dialysis, tonsillectomy, ichthyotherapy, etc.). These can be used alternatively to treat psoriasis patients who have mild/minimal lesions, are intolerant to conventional drugs, have developed side effects or achieved recommended cumulative dose, where comorbidities pose unusual therapeutic challenges, or may be as intermittent, rotational or combination treatment alternatives.

Mental health among people with psoriasis undergoing patient education in climate therapy

This study investigated the mental health of people with psoriasis undergoing patient education in climate therapy. A prospective design included a baseline assessment and two follow-ups after a 3-week patient education program. Participants were 254 adults. Positive mental health was measured by the mental health continuum short form (0-70), and negative mental health by the emotional distress subscale (1-4) of the health education impact questionnaire. Paired-samples t-tests were used to evaluate changes in mental health from baseline to follow-up. Multiple linear regression was used to analyse the ability of socio-demographic and clinical variables and emotional distress to predict changes in positive mental health. To predict change in negative mental health we repeated the same analysis but with a change in negative mental health as a dependent variable and positive mental health as an independent variable. The results show that positive mental health and health-related emotional distress improved significantly from before to after the intervention by 7.1 points, p < 0.001 and 0.21 points, p < 0.001) respectively. At the second follow-up, health-related emotional distress remained significantly improved compared with baseline levels by 0.11 points, p = 0.004. The longer participants had lived with psoriasis ( β = 146, p = 0.027), and the presence of co-morbid health problems (β  =  111, p = 0.051) the greater the improvement in the positive mental health immediately after the intervention. No predictors were identified for negative mental health. This study indicates that the promotion of positive mental health needs to be integrated into the climate therapy program, and sustained in their home context.

Psoriasis Patients' Knowledge about the Disease and Treatments

Patients' knowledge about psoriasis and its treatment has been randomly studied previously. The aim of the study is to investigate patients' knowledge about psoriasis in relation to undergoing patient education in the context of climate therapy (CT). The psoriasis knowledge questionnaire (PKQ) was used in a follow-up pre–post study design of Norwegian patients with psoriasis at the age of 20 years and older undergoing CT at Gran Canaria (Spain). Patients completed the PKQ and provided selected demographic, clinical and health information before (T1), immediately after (T2), and 3 months after (T3) CT. Disease severity was assessed using the psoriasis area and severity index (PASI). 254 psoriasis patients were included (74%). The PKQ score improved significantly from T1 to T2 and T3 (P < 0.001 for both comparisons). Although patient's knowledge improved, further research should use gold standard designs (experiments) to study the effects of educational interventions in different contexts.

Promoting sense of coherence: Salutogenesis among people with psoriasis undergoing patient education in climate therapy

Background

There is a need for further investigation of sense of coherence (SOC), the central concept of salutogenesis, and its relationship with long-term illnesses such as psoriasis. The aim of this study is to investigate the development of SOC during patient education in the context of climate therapy and to explore factors that may predict changes in SOC among people with psoriasis.

Methods

A prospective design included a baseline assessment and two follow-ups after a 3-week patient education and climate therapy programme (follow-up 1) and again 3 months later (follow-up 2). A total of 254 adults (aged 20–80) with psoriasis participated. SOC was measured by the SOC Questionnaire, illness perception was measured by the Revised Illness Perception Questionnaire, and positive and active engagement in life was measured by the positive and active engagement subscale of the Health Education Impact Questionnaire. Paired-sample t tests were used to evaluate changes in SOC from the baseline to follow-up. Multiple linear regression was used to analyse the ability of socio-demographic and clinical variables, illness perception and positive and active engagement in life to predict the changes in SOC.

Results

The SOC score changed significantly by 2.65 points, (95% CI = 0.621, 3.685) from the baseline to follow-up 1. SOC score was still improved by 1.15 points (95% CI = 0.073, 0.223) at follow-up 2.

Baseline and change in positive and active engagement in life were linked to change in SOC with standardized beta 0.170 (95% CI = 0.024, 0.319) and 0.259 (95% CI = 0.092, 0.428), respectively. In addition illness coherence perception at baseline and change in emotional representations were significantly associated with the change in SOC with standardized beta 0.212 (95% CI = 0.073, 0.361) and –0.270 (95% CI = –0.481, –0,077), respectively.

Conclusions

SOC improved significantly from before to after patient education in the context of climate therapy. The results indicate that improving positive and active engagement in life, coping with emotional distress and a coherent understanding of the illness might provide important opportunities to improve SOC among people with psoriasis.

Large-scale, prospective, observational studies in patients with psoriasis and psoriatic arthritis: A systematic and critical review

Background

Observational studies, if conducted appropriately, play an important role in the decision-making process providing invaluable information on effectiveness, patient-reported outcomes and costs in a real-world environment. We conducted a systematic review of large-scale, prospective, cohort studies with the aim of (a) summarising design characteristics, the interventions or aspects of the disease studied and the outcomes measured and (b) investigating methodological quality.

Methods

We included prospective, cohort studies which included at least 100 adults with psoriasis or psoriatic arthritis. Studies were identified through searches in electronic databases (Pubmed, Medline, Cochrane library, Centre for Reviews and Dissemination). Information on study characteristics were extracted and tabulated and quality assessment, using a checklist of 18 questions, was conducted.

Results

Thirty five papers covering 16 cohorts met the inclusion criteria. There were ten treatment-related studies, only two of which provided a comparison between treatments, and six non-treatment studies which examined a number of characteristics of the disease including mortality, morbidity, cost of illness and health-related quality of life. All studies included a clinical outcome measure and 11 included patient-reported outcomes, however only two studies reported information on patient utilities and two on costs. The quality of the assessed studies varied widely. Studies did well on a number of quality assessment questions including having clear objectives, documenting selection criteria, providing a representative sample, defining interventions/characteristics under study, defining and using appropriate outcomes, describing results clearly and using appropriate statistical tests. The quality assessment criteria least adhered to involved questions regarding sample size calculations, describing potential selection bias, defining and adjusting for confounders and losses to follow-up, and defining and describing a comparison group.

Conclusion

The review highlights the need for well designed prospective observational studies on the effectiveness, patient-reported outcomes and economic impact of treatment regimes for patients with psoriasis and psoriatic arthritis in a real-world environment.

Rehabilitation in a Warm Versus a Colder Climate in Chronic Obstructive Pulmonary Disease

PURPOSE

The primary aim of this study was to evaluate if pulmonary rehabilitation in a subtropical climate during winter had better long-term effects on health-related quality of life and symptoms of anxiety and depression than an equivalent pulmonary rehabilitation program in a colder climate. The secondary aim was to assess short-term differences in the same outcomes.

METHODS

Referred patients with chronic obstructive pulmonary disease were randomized to and completed rehabilitation in a subtropical climate in Spain (n=60) or in a temperate climate in Norway (n=36). Health-related quality of life was assessed with St. George's Respiratory Questionnaire, and symptoms of anxiety and depression were assessed with the Hospital Anxiety and Depression Scale at the start of rehabilitation, at discharge, and 8 months later.

RESULTS

There were no significant differences between the 2 groups in mean changes in St George's Respiratory Questionnaire dimensions or total score (-3.0; 97.5% confidence interval [CI], -8.6 to 2.6, P = .22) or Hospital Anxiety and Depression Scale anxiety (-1.2; 97.5% CI, -2.7 to 0.3, P = .08) or depression (-0.3; 97.5% CI, -1.7 to 1.1, P = .62) score from the start of rehabilitation to 9 months thereafter. During rehabilitation, the Spain group improved more than the Norway group in the activity score of the St George's Respiratory Questionnaire (-6.2; 97.5% CI, -12.4 to -0.1, P= .02) and in the Hospital Anxiety and Depression Scale anxiety score (-1.7; 97.5% CI, -2.9 to -0.6, P = .001).

CONCLUSIONS

No significant long-term differences in improvement in health-related quality of life or psychological well-being was demonstrated after chronic obstructive pulmonary disease rehabilitation in a subtropical versus a temperate climate.

Impact of psoriasis on health-related quality of life decreases over time: an 11-year prospective study

Although psoriasis typically affects patients for many years, studies quantifying impairment in health-related quality of life (HRQOL) owing to psoriasis over long periods are lacking. This study, which interviewed patients independent of psoriasis care, investigates change in the impact of psoriasis on HRQOL over 11 years and factors associated with change among 484 patients using the Impact of Psoriasis Questionnaire (IPSO). We determined changes in the impact of psoriasis on HRQOL using a psychometrically optimized version of the IPSO. In 1993, the patients were 53+/-11.4 years and 61.8% males. From 1993 to 2004, impact on most social aspects of HRQOL remained stable, but concerns related to physical appearance decreased (e.g., 36-13%, P = 0.001). Over 11 years, the proportion of patients with low overall impact of psoriasis increased significantly (43-53%, P < 0.001). Mean IPSO scores (range 0-22) decreased by one-fifth (5-4, P < 0.001). At follow-up, patients reporting poor health had mean improvement in HRQOL about three times greater than those in good health (P < 0.05). In this large cohort interviewed independent of treatments and psoriasis status, impact of psoriasis on HRQOL decreases over time. For chronic diseases, HRQOL is best measured over time and independently of seeking treatment.